Ambulance Wars

This week, Comptroller Alan Hevesi's office is finally releasing a long-awaited report showing that ambulances from private hospitals tend to take patients back to their own rather than the nearest emergency roomseven when the patient has a life-threatening condition. Analyzing strictly guarded data from the Fire Department (which now runs city ambulances), the report proves that private hospital ambulance crews have been steering patients back to the hospitals that pay them and away from the public hospitals. This dangerous and sometimes illegal practice is financially devastating to the city's cash-strapped public hospital system.

Private ambulances are 10 to 25 times more likely to go back to their sponsoring hospitals than are city ambulances in the same zip code, according to the report. Ambulances operated by Our Lady of Mercy Medical Center in the Bronx, for instance, were roughly 16 times more likely than city ambulances to bring patients in a certain area back to that hospital, even though it entailed bypassing the closer public hospitalNorth Central Bronx. The report also showed that private hospitals stole patients from each other.

Perhaps most damning, the studywhich was based on the records from more than 300,000 transports made in five months of 1999found that private ambulances are twice as likely to steer insuredas opposed to uninsuredpatients to their home base. The findings confirm the results of a months-long Voice investigation of patient poaching and ambulance drop-off patterns. They also provide statistical evidence of what emergency-services veterans have long referred to as the "wallet biopsy." "Make sure the patients you bring back are the ones with the AmEx and Visa cards," is how one paramedic who used to work for a private hospital explains the unofficial procedure.

City-operated emergency-services vehicles and private ambulances have shared the responsibility for answering New York's 911 calls for more than 20 years. And for perhaps as long, the two sides have accused one another of selectively snatching paying patients. In February of last year, MetroCarewhich is arguably the largest ambulance company and is owned by Giuliani contributor Steve Zakheimbecame the first of several independent ambulance companies to work on behalf of private hospitals, when it contracted with St. Barnabas Hospital in the Bronx.

Now, with financial pressure on hospitals heating up (at least two private hospitals in the city have flirted with bankruptcy in the last year), competition for insured patients has gotten even more furious. A few hospitals woo ambulance crews with free food and coffee; multiple ambulances sometimes vie for the same call; MetroCare even sends direct-mail follow-up suggesting that in the future patients call them directly in an emergency.

"In the last three or four years, people have begun fighting over patients," is how the director of the emergency department of one municipal hospital sums up the climate. "There's no oversight of who goes where."

The city doesn't pay private hospitals for providing emergency service. Instead, there's a tacit trade-off: In exchange for tending to car wrecks and heart attacks, private hospitals and the private ambulance companies that work for them use their "buses," as emergency workers call them, to bring revenue-generating patients back to their hospitals. Moreover, under a deal formalized last April between the Fire Department and the Greater New York Hospital Association, private ambulances are allowed to charge whatever they want. Patients picked up by private ambulances could pay as much as $800 when the city's top rate is $450 (see sidebar).

With the exceptions of trauma, burn, and dismemberment victims, who must go to specialized centers, those with life-threatening emergencies must go directly to the nearest qualified hospital, according to FDNY regulations. If they're not on death's door, though, patients are allowed to choose to go to a more distant hospital as long as it's not more than 10 minutes from the nearest one. But insiders say ambulance operators flout those rules in several ways, including taking unconscious or confused patients to the ambulance's home-base hospital even if it's not the closest; not letting patients know they have a choice of hospitals; and sometimes even overriding patients' choices.

The pull of finances can do more than critically lengthen ambulance rides. It can also slow response times, according to emergency physician Stephan Lynn. "When patients are driven further, the next patient that calls an ambulance pays the price," says Lynn. The ambulance "takes itself out of service for an additional five or 10 minutes and the system becomes less effective."

Directing well-heeled patients to private hospitals and poor people to increasingly struggling public hospitals also helps shape a divide between the health care of the rich and poor so deep it's become a part of the city's medical culture. The "wallet biopsy" partly explains how more than 40 mostly black and Latino patients made their way to Bellevue's emergency room on a recent afternoon, while a mere six patients awaited attention a few blocks uptown in NYU Medical Center's air-conditioned emergency room. But the effects of patient-sorting by ambulance crews can be even subtlera matching of patient and hospital that goes beyond mere dollars.

"EMTs and paramedics are not likely to ask the question 'Do you have insurance?' " as one physician who specializes in emergency care at a city hospital explains. "They're likely to look at what car you're driving, what clothes you're wearing, what neighborhood you live in, and then make a judgment" about where to take you.

Another doctor, who works in Bellevue's emergency room, uses Grand Central Terminal to explain the situation: "If they pick you up on the Metro-North level, chances are, you're going to Cornell [Medical Center]," he says. "But if you're on the subway level, you're probably coming here."

In fact, even while ambulances from New York Hospital, Cabrini, and St. Clare's steer patients away from Bellevue, the public hospital on First Avenue in Manhattan has become a destination for ambulances carrying homeless and drunk patients. One ambulance recently drove an intoxicated man to Bellevue all the way from St. Nicholas Avenue and 126th Street, passing Mount Sinai, Lenox Hill, and St. Luke's-Roosevelt, among other private hospitals, on its way to the public emergency room. The paperwork for the man's delivery indicated that the patient had chosen Bellevue, which could theoretically justify such a detour (if it had somehow added only 10 minutes to the trip), though a doctor who was present at the time of the delivery said the man was incoherent when he arrived.

The carting of insured patients to private hospitalsand away from public onesalso further weakens a public system that's already dangerously depleted. The number of patients in public hospital beds dropped 39 percent between 1994 and 1999. This year, the Health and Hospitals Corporation is in arguably the worst shape of its recent past, facing a $313 million deficit even as it treats a greater number of uninsured patients than ever before.

On June 7, an ambulance run for Montefiore by MetroCare responded to a 911 call on behalf of Michael Fusco, a 92-year-old man living in the Norwood section of the Bronx. Though he wasn't able to ride along, Fusco's neighbor and caretaker, James Diaz, told the paramedics to take the ailing man to North Central Bronx Hospital, where Fusco had been getting regular checkups. "There was nothing confusing about what I said," remembers Diaz. "I was speaking the King's English." Despite his clear request, though, the ambulance took the patient back to its home base, which is on the same square block as North Central Bronx.

Fusco, who turned out to have pneumonia, checked himself out of Montefiore the same day. When his symptoms worsened the following day, Diaz summoned another ambulance, this time riding along to make sure it reached the appropriate destination. But even with Diaz in the bus asking to go to North Central Bronx, the paramedic's homing instincts took over. "He started going down the ambulance drive to Montefiore," recalls Diaz. "I said 'Where are we going?' and then he turned and went back to North Central."

MetroCare's Zakheim, whose company wasn't working in New York City during the period of the comptroller's audit, denies that his ambulances are ever involved in patient steering. "We base the destination on either the patient's choice or the condition of the patient as per the Fire Department protocols," says Zakheim. "I receive no reward by bringing more or less patients to any hospital whatsoever."

According to paramedics and EMTs, there's considerable pressure to make trips to home baseand deliver paying patients to their employers. "If you work for a particular hospital, your marching orders are bring patients back there," says an EMT who has worked for both a private hospital and the Fire Department.

A former emergency director of one Bronx hospital, who didn't want his name used for this article, describes the intense financial competition for patients this way: "Every month we get statistics about exactly who's not bringing the patients back. EMTs had their jobs threatened if they didn't bring patients back to the mother ship," he says. "It's almost like the people who are good at that are given opportunities for promotion. There's a lot of pressure, because even for the uninsured you can sometimes get coverage."

Indeed, running their own ambulances or hiring private companies has proven to be a financial boon to hospitals. After Community Hospital in Brooklyn enlisted MetroCare, a private company, to run ambulances for it in March of last year, the number of patients in the hospital's emergency room leapt from 1896 to 3493. Similarly, after Kings Highway Hospital hired the same company in the summer of 2000, their admissions almost doubled.

And when private hospitals gain patients, city hospitals lose them. All but one public hospital had a reduction in ambulance deliveries between 1990 and 1999, according to the report. In that period, Queens Hospital saw its share of ambulance transports in the borough drop by more than two-thirds. It was this hemorrhaging of patients that first spurred Bernie Diamond, chair of the Queens Hospital Center Community Advisory Board, to ask Comptroller Hevesi to do an audit of the emergency medical system back in October of 1997. "The ambulance drivers were bypassing Queens Hospital and taking them to the hospital that paid their wages, but we couldn't prove it because we didn't have all the evidence," says Diamond. "So I asked the comptroller, since he had the staff to do audits."

Hevesi's initial response was prompt: "We will jointly evaluate whether EMS ambulances are diverting financially viable patients away from HHC hospitals," the comptroller wrote back to Diamond in December of 1997. After that, though, the investigatory process dragged on, leaving frustrationand speculationin its wake. "The comptroller may be worried about making a mistake in his run for mayor," Diamond offered by way of explaining the report's delay.

Internecine politics surrounding the emergency system have made its problems a particularly touchy subjecteven for an ambitious mayoral hopeful. Several politically powerful groups have an interest in defending the growing role of non-city ambulances in the 911 system. These include the Greater New York Hospital Association; 1199, the large union that represents ambulance workers for those hospitals; and owners of private ambulance companies.

Nevertheless, politicians have been jockeying for position on the issue. Both Mark Green and Hevesi have endorsed a lawsuit against Fire Commissioner Thomas Von Essen and Giuliani, among others, which charges that the city inappropriately allowed private companies into the 911 system. Joining Local 2507, the union that represents Fire Department ambulance workers (and has its own stake in protecting its professional turf), the candidates are arguing that the private contractors, like MetroCare, should be ousted from EMS.

The mayor's other major initiative involving emergency servicesto put ambulances under the control of the Fire Department in 1996has also proven controversial. Former EMS medical director Lorraine Giordano, a physician, is worried about the Fire Department's medical standards. "I wanted to keep the 'medical' in EMS," said Giordano who lost her job in December 1999, after raising concerns about proposed cost-cutting measures. Fire Department spokesman Frank Gribbon responds, "The standards are set by the state. We've always adhered to them. We always will."

Whether patient steering will continue to happen is likely to be up to the next administration to decide. And even a mayor committed to healing our deeply divided emergency system may find it difficult. "As long as ambulance staff feel they have a responsibility to a public or private hospital, the system will always be out of balance," says Lynn.